Wednesday, December 16, 2015

Most programs for people who have
sexually abused say they follow Risk, Need, and Responsivity. This is a good
thing, but do they really do that? We know that some programs ignore risk,
while others don’t really focus on specific client needs. In my opinion,
however, the biggest problem with RNR is that we still don’t know what to make
of responsivity.

I work with a lot of clients with intellectual
disabilities or other cognitive problems. I try to make sure that clients get
assessed, treated, and managed in a way that fits their special needs, but what
do I mean by special needs? Is it just low IQ or some kind of brain injury, or
do we need to think about other problems? What about fetal alcohol effects?
What about mental illness? Also, what about clients who were in prison for a
very long time who can’t think so well anymore because prison didn’t give them
much practice? This definition may be a bit broad, but the point I really want
to make is that clients with special needs require special treatment – with
specialized tools and procedures. Sometimes, this means we have to be creative.

Now that we know who the special needs
people are, how we help them with their problems? A real problem with many
programs is that they don’t have books or exercises that were made for special
needs clients. Can we use those programs as they were originally written? Do we
just talk slower? Do we make the program longer and give it in smaller bits? Research
and experience tell us that slower and longer may help some clients, but no
special changes at all doesn’t really work. Slower and longer may also lead to
problems. My good friend tells a story of his early career when he was trying
to explain something to an intellectually disabled client – slower and longer. After
getting frustrated, the client said, “Man, I’m retarded. I’m not stupid!” Easier
language, with more pictures, repetition, and social stories helps. We also
need to remember that nobody likes to have their nose rubbed in their problems,
so respect is also really important. What we work on may end up being pretty much
the same, but we need to remember that special needs requires special attention.

Managing risk also requires a different approach.
Sadly, many special needs clients will never enjoy the same quality of life as their
friends without difficulties. A lot of staff are now focused on the idea that special
needs clients have the same rights as people without disabilities or cognitive
problems. I’m not totally sure about this. I agree that all special needs
clients should be able to live as normal a life as possible, but I think we
need to be realistic. Do our special needs clients also have the right to good
service? What if getting good service means that some clients won’t get to do what
they want to? Is that fair? I understand the need to ensure equal opportunity,
but being kind and caring enough not to let clients fail is also important.
Bill Marshall says Warm, Empathic, Rewarding, and Directive – I agree.

So, that’s 529 words…but they’re 529 words
with an average character length of 4.5 and an overall Grade level of 7.2.
Still too high for most of our special needs clients, but keep in mind, I’m a
psychologist.

Thursday, December 10, 2015

In 1974, Robert
Martinson published a now-classic text concluding that he was unable to find
evidence of the effectiveness of rehabilitative efforts for people involved in
the criminal-justice system. Although a section of his essay was titled, “Does
nothing work?” it became known as the “nothing works” doctrine. Despite the
fact that Martinson himself essentially admitted he had been wrong (Martinson,
1979), the nothing works doctrine held sway for many years until Canadian
criminologists such as Paul Gendreau introduced the “something works” doctrine
(meaning that it was clear that rehabilitative efforts could work, even if the
exact mechanisms remained unclear), and eventually the “what works” doctrine
that followed (e.g., Gendreau & Ross, 1987).

What works in
treatment seems clear enough, but is it really? The principles of effective
correctional rehabilitation (i.e. risk, need, and responsivity) state that we
should provide more intensive treatments to those who pose the highest risk,
focus on empirically supported treatment goals, and use empirically supported
techniques (e.g., CBT).The responsivity
principle further states that we should match treatment to the individual characteristics
of each client (e.g., cognitive ability, culture, mental health needs,
motivation).

From such simple
principles many controversies can emerge and great minds can disagree.For
example, one client who has sexually offended against children might benefit
from treatment addressing interpersonal skills in such a way that sex with
children is unnecessary and undesirable because of the client’s ability to form
intimate relationships with adults. Another client might reap minimal benefits
from such treatment, because it is the combination of sexual interest in
children and a suite of beliefs supporting abuse that contributes more to his
risk. As Tony Ward recently pointed out (Yates, Prescott, & Ward, 2010), absent an
explanatory means for understanding risk factors, they may simply be markers
for further investigation and understanding in programs that seek to reduce
risk and build capacities.

There is no
question that the principles of risk, need, and responsivity are vital
contributors to “what works” in treatment. However, a robust research
literature both inside and outside our field points to the fact that who the
professional is can be a vital contributor to building responsivity and beyond.
As a result, we are proposing a “who works doctrine” alongside the what works
doctrine. The name is intended to be provocative and only slightly
tongue-in-cheek, and intended as a homage to those brilliant researchers who
came before us. To illustrate the importance of thinking in terms of “who
works” in addition to what works, it may be helpful to review influential
developments of the past.

In 1979, Edward
Bordin proposed a model of the therapeutic alliance that involved agreement on
the nature of the therapeutic relationship, and agreement on the goals and
tasks of treatment. Subsequent research by Jon Norcross and others would also
highlight the importance of having therapy take place in the context of strong
client preferences (Norcross, 2011). These four areas: agreement on the nature
of the relationship, goals, tasks, and values form the basis of a critical
element of treatment. Over a thousand studies have pointed to the contribution
of the alliance to successful therapy outcomes. Recent research has highlighted
the importance of clinicians getting feedback from their clients in these areas
(e.g., Lambert, 2010; Prescott & Miller, 2015). In fact, one can argue that
attention to the alliance is amongst the most evidence-based therapeutic
activities there is. Without it, targeting criminogenic needs is useless, and a
greater waste of resources for those at highest risk (since they presumably
receive the most treatment).

Likewise, Bill
Marshall’s classic 2005 summary of research that he conducted with others
points to the qualities of the most effective professionals (Marshall, 2005).
They are warm, empathic, rewarding, and directive (in the sense of being able
to guide people and processes. However, much of our field remains influenced by
early texts and professionals who advocated a more overtly confrontational
approach (e.g., Salter, 1988). Indeed, a 2008 meta-analysis by Karen Parhar and
her colleagues found that the more coercive the treatment experience, the less
likely it is to be effective (Parhar, Wormith, Derzken, & Beauregard,
2008). Most recently, Theresa Gannon and Tony Ward published an important paper
titled, “Where has all the psychology gone?” that illustrated how far
correctional programs can stray from what – and who – works in helping people
in the legal system to rebuild their lives (Gannon & Ward, 2014).

Elsewhere in the
psychotherapy literature, there is evidence that there is a greater difference
in success between therapists practicing within a model than there is between
models themselves (Wampold & Imel, 2015). Likewise, there is considerable
evidence that the most effective practitioners in any endeavor tend to spend
more time engaging in activities meant to improve their skills and outcomes (Ericsson,
XXX). It is important to separate deliberate practice aimed at improvement from
simply practicing a lot. More hours doing the same thing can be just that –
doing more of the same. This is particularly crucial when one considers
research finding that therapists often overestimate their effectiveness (e.g.,
Beech & Fordham, 1997; Walfish, McAlister, O’Donnell, & Lambert, 2012).

However, in some
quarters, our field is paying less attention to therapeutic variables and
focusing on cutting costs by engaging in a very high level of manualization at
the expense of a deeper and more meaningful treatment experience (Albright,
2015). There is no reason to believe this will work. For example, Janice
Marques and her colleagues found in a randomized clinical trial that there was
no difference in re-offense rates between those who did and didn’t complete
abuse-specific treatment, although those who “got it” and meaningfully
completed their treatment goals really did re-offend at lower rates, although
these individuals received no further study. It is therefore not difficult to
see how over-manualization (e.g., highly scripted rather than individualized)
can easily result in problems adhering to the responsivity principle.

What works in
treatment? We propose it is time for a return to a greater attention to factors
related to specific responsivity and
to draw on the existing psychotherapy research. Areas of focus can include:

·A return to thinking of our
programs as delivering therapy and not simply treatment

·Greater attention to the
professional self-development of therapists

·Increased recognition that society’s
attempts to use punishment-only approaches are almost entirely ineffective,
while the right therapy and right supervision can make an impact on re-offense
rates, community safety, and client well-being.

·A greater awareness of the role
of adverse experiences in the lives of clients and a greater fine-tuning of
therapy in order to help clients understand how adverse events have shaped
their lives and provide avenues for growing beyond the effects of these
experiences.

·Greater attention to what is
important in clients’ lives (e.g., drawing on the Good Lives Model; Ward
citation).

In many environments,
this will involve a return to viewing therapists as the professionals and
experts that they are. After all, the very definition of evidence-based
practice includes clinical expertise as well as best available research and in
accordance with client characteristics.

Friday, December 4, 2015

Cordelia has been working in the
field of sexual harm for nearly 40 years traversing the landscapes of research,
treatment and victim advocacy with a focus on prevention, reduction and
support. Cordelia believes that the best way to prevent sexual harm is to fully
understand its causes, the perpetrators and its victims; we need a holistic,
informed and multi-dimensional approach. In order to develop a shared,
systematic approach to preventing sexual harm we need to recognise that that
what are often seen as different [opposing] sides of the sexual harm field
[treatment providers vs. victim advocates vs. criminal justice professionals
vs. the ‘public’] are not actually opposed, instead they are actually
complementary and we need to get better at drawing them together through
language as well as action. Which means that in order to prevent sexual harm we
need to be able to see the being picture, we have to be able to dance between
the disciplinary ‘puddles’ [like Cordelia has across her career], or get out of
our silos, of sexual harm.

At the core of Cordelias’ work is
the belief that sexual harm is preventable, that we should be working towards
eradicating it rather than just simply reducing it. The language of public
health and health care was used a lot in the interview with Cordelia pointing
out that sexual harm is not a distinct and separate [a one-off occurrence], but
rather connected to a range of social, psychological, cultural and
developmental issues [so part of an eco-system or constellation of issues]. Preventing
sexual harm is tied to public health, criminal justice and social justice; we
need to understand why and how it happens before we can stop it.

Interestingly, using the health
analogy I asked Cordelia if sexual harm could be considered as part of a
disease model like cancer or HIV to which she responded “sexual harm is
endemic, not an epidemic”. She expanded upon this answer by asking me to
consider why society has not responded to sexual harm fully in the past? Why
society is willing to accept that some people will be the victims of sexual
harm? Who controls and directs the conversations about sexual harm? Are we
willing to challenge these individuals, organisations or platforms on the
messages that they convey? We need to examine the social attitudes to sexual
harm and its ‘acceptability’ before we can eradicate it; therefore it seems
that it is both endemic and an epidemic. Although, the eradication of something
so prevalent in society seems like a tall order, or even impossible, she
believes that it is possible if we all work systematically and collectively on
the issue.

In discussing her career Cordelia
points out how far we have come since the 1970’s when sexual harm was not
really discussed [especially in respect to children] to the stage where we are
at now where it is more widely discussed and more fully accepted. She points
out that we know more about the causes of sexual harm and its impact than ever
before, with on-going research and treatment solidifying the base [i.e., the
importance of attachment, the impact of child abuse and neglect on development
across the lifespan, the importance of family dysfunction] as well as revealing
new fields [i.e., attachment, desistence, trauma informed care]. We still have
a way to go to completely eradicate sexual harm; but we are moving in the right
direction and will continue to do so the more that we share information across
our silos.

Cordelia believes that in order
to eradicate sexual harm there are certain actions that we should be carrying
out, or should be happening more often, including, [1.] continuing to breakdown
disciplinary silos so that we can see the big picture; [2.] that victim
advocates and other professionals who work in the field of sexual harm
recognize that they are more effective when they

work together; [3.] that society
has to own the problem of sexual harm, not passing it off to professionals, as
that is the only way that we will eradicate it; and [4.] we have to be critical, constantly
critical, of current approaches to eradicating sexual harm asking whether they
are suitable and/or fit for purpose.

Talking with Cordelia was
interesting and refreshing, especially given that the sexual harm field has
finally caught up to the multi-disciplinary approach to prevention that she has
been advocating for the last 40 years.

Kieran McCartan, PhD

Chief Blogger

David Prescott, LICSW

Associate blogger

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The Association for the Treatment of Sexual Abusers (http://atsa.com/) is an international, multi-disciplinary organization dedicated to preventing sexual abuse. Through research, education, and shared learning ATSA promotes evidence based practice, public policy and community strategies that lead to the effective assessment, treatment and management of individuals who have sexually abused or are risk to abuse.

The views expressed on this blog are of the bloggers and are not necessarily those of the Association for the Treatment of Sexual Abusers, Sexual Abuse: A Journal of Research & Treatment, or Sage Journals.

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